DISCLOSURES NONE Felicia Lester, MD MS MPH OUTPATIENT INDUCTION OF LABOR Associate Professor Obstetrics, Gynecology and Gynecologic Surgery Dept of Ob/Gyn & RS, UCSF 1 2 INDUCTION OF LABOR CERVICAL RIPENING • Takes 12- 24 hours • 25% of women currently undergo labor induction Many anticipate this will increase with ARRIVE • Initial stage of IOL for patient with low Bishop score • Implications for: (<6) • Patient satisfaction • Length of stay • Traditionally takes place in hospital • Healthcare costs • Facility capacity • Many institutions have moved to outpatient 3 4
OUTPATIENT FOLEY BALLOON: SAFETY MECHANICAL VS PHARMACOLOGIC RIPENING • Not associated with tachysystole, fetal intolerance Mechanical Pharmacologic of labor or meconium staining (Cochrane, 2009) • Inpatient cohort nearly 2,000 women (Sciscione, 2014) • No c/s for distress, vaginal bleeding, abruption, or stillbirth • Few outpatient studies • No increased maternal or neonatal complications (McKenna, 2004; Kuper, 2018; Wilkinson, 2015; Kruit, 2016) • No increased infectious morbidity, PPH, c/s, operative delivery or fetal distress 5 6 OUTPATIENT FOLEY BALLOON: SATISFACTION OUTPATIENT FOLEY BALLOON: EFFICACY • Pilot study of inpatient vs outpatient FB (Wilkinson, 2015) • Equally satisfied and equally likely to • Outpatient vs Inpatient (Policiano, 2017) recommend • Similar change in bishop score • Outpatient: more rest, adequate privacy, less • Outpatient isolated • Less time from application to delivery (38 vs 44 • Discrete choice experiment: women would be hrs) willing to have an extra 1.4 trips and 73 minutes • 10 hours less time in the hospital of travel time for outpatient (Howard, 2014) • Vaginal delivery rate 72% vs 62% (not sig) • 85% of women having outpatient FB were • Lower CD for failed IOL (3% vs 17%) satisfied, no comparison group (Kruit, 2016) 7 8
OUTPATIENT PROSTAGLANDIN: EFFICACY OUTPATIENT PROSTAGLANDIN: SAFETY • Administering outpatient miso may shorten time to spontaneous labor and avoid need for • Compared to FB, associated with tachysystole, formal induction fetal intolerance of labor or meconium staining • 100 µg PO q 24 hrs x 3 doses for PD decreased (Cochrane, 2009) • Outpatient studies thus far have not reported an time to delivery b 1.5 days (Gaffaney, 2009) increase in adverse fetal outcomes or out of • 25 µg PV x 1 with sweeping reduced time to delivery by 2 days (PonMalar, 2017) hospital deliveries (Lamar, 2019) • 25 µg PV q 24 hrs x 2 doses in 48 hrs before • With rational administration and monitoring planned PD IOL: 85% went into spontaneous labor after initial dose, should be safe vs 11% in control (Stitely, 2000) • Misoprostol: max blood levels 30 mins after oral • Outpatient vs inpatient prostaglandin (miso, PGE2 and 70-80 after vaginal administration gel and insert) • Decreased time on L&D (Chang, 2005; Biem, 2003; Wilkinson, 2015) 9 10 RATIONAL OUTPATIENT IOL PROTOCOL WITH OUTPATIENT PROSTAGLANDIN: SATISFACTION FOLEY BALLOON (LAMAR, 2019) • PROBAAT-II Study: FB vs miso IOL Inpatient • 12% vs 6% of women would have preferred Absolute Contraindications Relative Contraindications • Contraindication to Vaginal Delivery • Unreliable phone access or transportation another method of IOL (Ten Eikelder, 2017) • Nonreactive Stress Test or BPP <6 • Demonstrated difficulty attending prenatal appointments • Outpatient vs inpatient PGE2 insert • High-risk medical or Obstetrical Condition • Previous uterine scar • Placental Abruption or active vaginal bleeding • 56% vs 39% highly satisfied with first 12 • Intrahepatic cholestasis of pregnancy • Preterm gestation • Bishop Score >6 hours of IOL (Biem, 2003) • Rupture of membranes • Fetal growth restriction • Oligo or Poly • Need for immediate neonatal resuscitation • Patient unable verbalize understanding of care plan or instructions 11 12
RATIONAL OUTPATIENT IOL PROTOCOL WITH RATIONAL OUTPATIENT IOL PROTOCOL WITH FOLEY BALLOON (MODIFIED FROM LAMAR, 2019) PROSTAGLANDIN Patient determined to be appropriate Procedure scheduled in outpatient candidate for outpatient FB by clinical clinic one day prior to scheduled IOL Contraindications Patient provides informed consent After reactive NST, FB placed Use Foley Balloon criteria but with prior digitally or visually through uterine NST performed, ultrasound for fetal cervix filled with 30-60 mL NS, uterine scar as absolute contraindication presentation, Bishop score clamped determined IF NST not reactive, painful UC >3 in 10 mins or oligo/poly, NST performed. If reactive and malpresentation, not candidate patient stable, postprocedure and return precautions reviewed If amniotomy, increased VB, NST not reactive, frequent UCs or other concerns, to L&D 13 14 RATIONAL OUTPATIENT IOL PROTOCOL WITH IF IT WERE RECOMMENDED FOR YOU TO HAVE AN IOL PROSTAGLANDIN WITH A FOLEY BALLOON, WOULD YOU WANT… Patient determined to be appropriate Medication administration scheduled 83% candidate for outpatient misoprostol in outpatient clinic one day prior to by clinical A. Inpatient Foley Balloon? scheduled IOL Patient provides informed consent B. Outpatient Foley Balloon? NST performed, ultrasound for fetal After reactive NST, misoprostol presentation, Bishop score 50mcg PV administered determined 17% IF NST not reactive, painful UC >3 in 10 mins or oligo/poly, NST performed for 90 minutes. If malpresentation, not candidate reactive and patient stable, ? ? anticipatory guidance and return n n o o o o l l l l a a B B precautions reviewed y y e e l l o o F F t t n n e e If NST not reactive, frequent UCs t i t i a a p p n t u I O or other concerns, to L&D 15 16
IF YOUR PROVIDER RECOMMENDED IT, WOULD IF IT WERE RECOMMENDED FOR YOU TO HAVE AN IOL YOU ACCEPT… OUTPATIENT FOLEY BALLOON WITH PROSTAGLANDINS, WOULD YOU WANT… 57% A. Inpatient Prostaglandin? A. Yes 43% 88% B. Outpatient Prostaglandin? B. No 12% ? ? n n d i i d n n a a l l g g a a t s t o s o r r P P t t n n e e i i t t a a p p n t I u s o O e N Y 17 18 REFERENCES IF YOUR PROVIDER RECOMMENDED IT, WOULD Lamar R, Mengesha B, Little S. The case for outpatient cervical ripening for IOL at term for low-risk pregnancies. OBG Management. Vol 31 YOU ACCEPT… OUTPATIENT PROSTAGLANDIN No. 9; Sept, 2019. Jozwiak M, Bloemenkamp KW, Kelly AJ, et al. Mechanical methods for induction of labor. Cochrane Database Syst Rev. 2012;(3):CD001233 ACOG Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin no. 107: induction of labor. Obstet Gynecol. 2009;114(2 pt 1):386- A. Yes 397. Reaffirmed 2019. 67% Sciscione AC, Bedder CL, Hoffman MK, et al. The timing of adverse events with Foley catheter preinduction: implications for outpatient use. Am J Perinatol. 2014;31:781-786. B. No McKenna DS, Duke JM. Effectiveness and infectious morbidity of outpatient cervical ripening with a Foley catheter. J Rerod Med. 2004;49:28- 32. Kuper SG, Jauk VX, George DM, et al. Outpatient Foley catheter for induction of labor in parous women: a randomized controlled trial. Obstet 33% Gynecol. 2018;132:94-101. Wilkinson C, Adelson P, Turnbull D. A comparison of inpatient with outpatient balloon catheter cervical ripening; a pilot randomized controlled trial. BMC Pregnancy Childbirth. 2015;15:126. Kruit H, Heikinheimo O, Ulander VM, et al. Foley catheter induction of labor as an outpatient procedure. J Perinatal. 2016;36:618-622. Sciscione AC, Muench M, Pollock M, et al. Transcervical Foley catheter for preinduction cervical ripening in an outpatient vs inpatient setting. Obstet Gynecol. 2001;98(5 pt 1):751-756. s e o Y N Policiano C, Pimenta M, Martins D, et al. Outpatient versus inpatient cervix priming with Foley catheter: a randomized trial. Eur J Obstet Gynecol Reprod Biol. 2017;210:1-6. 19 20
REFERENCES CONT../ Howard K, Gerard K, Adelson P , et al. Women’s preferences for inpatient and outpatient priming for labour induction: a discrete choice experiment. BMC Health Serv Res. 2014; 14:330. Gaffaney CA, Saul LL, Rumney PJ, et al. Outpatient oral misoprostol for prolonged pregnancies: a pilot investigation. AM J Perinatol. 2009;26:673-677. PonMalar J, Benjamin SJ, Abraham A. et al. Randomized double-blind placebo controlled study of preinduction cervical priming with 25 µg of misoprostol in the outpatient setting to prevent formal induction of labor. Arch Gynecol Obstet. 2017;295:33-38. Stitely ML, Browning J, Fowler M, et al. Outpatient cervical ripening with intravaginal misoprostol. Obstet Gynecol. 2000;96(5 pt 1):684-688. McKenna DS, Ester JB, Proffitt M, et al. Misoprostol outpatient cervical ripening without subsequent induction of labor: a randomized trial. Obstet Gynecol. 2004;104:579-584. Chang DW, Velazquez MD, Colyer M, et al. Vaginal misoprostol for cervical ripening at term: comparison of outpatient vs. inpatient administration. J Reprod Med. 2005;50:735-739. Biem SR, Turnell RW, Olatunbosum O, et al. A randomized controlled trial of outpatient versus inpatient labour induction with vaginal controlled- release prostaglandin-E2: effectiveness and satisfaction. J Obstet Gynecol Can. 2003;25:23-31. 21
Recommend
More recommend
